Provider Demographics
NPI:1104318476
Name:ROBERTS, MICHELLE DAWN (LPC, NCC)
Entity type:Individual
Prefix:PROF
First Name:MICHELLE
Middle Name:DAWN
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LPC, NCC
Other - Prefix:PROF
Other - First Name:MICHELLE
Other - Middle Name:DAWN
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MED, MSJ, LPC, NCC
Mailing Address - Street 1:1034 S BRENTWOOD BLVD STE 555
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-1265
Mailing Address - Country:US
Mailing Address - Phone:503-484-4078
Mailing Address - Fax:
Practice Address - Street 1:1034 S BRENTWOOD BLVD STE 555
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-1265
Practice Address - Country:US
Practice Address - Phone:503-484-4078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-03
Last Update Date:2018-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016040414101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health